10-07-2006, 12:24 AM
A 45-year-old woman presents to your office after developing a pruritic rash and a fever. She first noticed it on her wrists two weeks ago but states that it has now spread to her feet as well. Her past medical history is significant for a seizure disorder following the removal of a meningioma. She has been treated with Dilantin. Physical examination is significant for icteric sclera. There are polygonal, flat-topped, violaceous papules limited to her wrists and her ankles. A white, reticulated, lacy lesion is also evident on examination of her buccal mucosa. Her liver is enlarged and is nontender to palpation. Laboratory analysis reveals: PT 11 seconds, albumin 3.6 g/dL, alkaline phosphatase 160 U/L, AST 700 U/L, ALT 960 U/L, ANA 1:160. Anti-hepatitis C virus (second generation) is negative; anti-hepatitis-B surface antibody (HBs) is positive; and anti-hepatitis-B core antibody (Hbc)is negative. She has an erythrocyte sedimentation rate of 20 mm/h and a cholesterol of 160 mg/dL. Anti-smooth muscle antibody test is negative, and an ultrasound of the abdomen is normal. What would you do next?
(A) Start prednisone
(B) Initiate interferon--2b therapy
© Administer N-acetylcysteine
(D) Stop Dilantin
(E) Start methotrexate
(A) Start prednisone
(B) Initiate interferon--2b therapy
© Administer N-acetylcysteine
(D) Stop Dilantin
(E) Start methotrexate